Panhypopituitarism and diabetes insipidus in a patient with primary central nervous system lymphoma

Abstract

Primary central nervous system (CNS) lymphoma represents less than 5% of non-Hodgkin lymphomas, mainly of the B-cell type. We recently diagnosed a relapse of primary CNS lymphoma, resulting in panhypopituitarism and diabetes insipidus. Th is complication has rarely been described in the literature. Due to the patient ' s palliative situation, treatment was adapted to the context and only minimally invasive tests were performed to make the diagnosis.A 57-year-old woman was diagnosed with a diff use large B-cell primary cerebral lymphoma. After one course of high-dose corticosteroids and two courses of high-dose intravenous cytarabine and methotrexate, whole-brain radiotherapy (39 Gy) was successfully administered. Brain magnetic resonance imaging (MRI) confi rmed a complete remission. One year after the initial diagnosis, the patient was readmitted for confusion. She had urinary incontinence with polyuria, polydypsia and a recent 2 kg weight loss, with ataxia and paresis of oculomotor nerve III. Daily medication included dexamethasone 1.5 mg. A brain computed tomography (CT) scan identifi ed a 2.7 cm left thalamo-pedoncular lesion with a mass eff ect on the left lateral and third ventricles. Th e lesion was contrastenhanced and surrounded by an important edema. MRI of the brain further identifi ed hypothalamic and probably pituitary invasion ( Figure 1). Th e history of CNS lymphoma, brain images and clinical presentation were all suggestive of brain lymphoma recurrence. Lumbar puncture showed a few lymphocytes in the cerebrospinal fl uid. Disease staging excluded other lesions. Blood analysis identifi ed hypoglycemia, a very low thyroid stimulating hormone (TSH) value at 0.02 μ IU/mL (normal [N] ϭ 0.20 -4.20) with normallow free thyroxine (T 4 ) at 8.6 pg/mL (N ϭ 7.0 -17.0) and hypernatremia at 155 mmol/L (N ϭ 135 -145). Additional antepituitary hormone levels were examined. Luteinizing hormone (LH), follicle stimulating hormone (FSH) and estradiol levels were very low. Luteinizing hormone-releasing hormone (LH-RH) and thyrotropin-releasing hormone (TRH) tests confi rmed central hypogonadotropic hypogonadism and central hypothyroidism. Th e prolactin serum level was increased fi ve-fold above the normal range, suggesting a defect in the pituitary stalk. Insulin-like growth factor-1 (IGF-1) levels were normal, but growth hormone (GH)stimulating tests were not performed. Because the patient was immediately treated with methylprednisolone, the corticotropic axis could not be investigated. Analyses exploring the post-pituitary were also performed. Th e 24 h urinary volume was 4800 mL with a low osmolality of 204 mOsm/ kg (N ϭ 50 -1200), with the patient receiving 500 mL of parenteral fl uids and drinking more than 3500 mL per day. Plasma osmolality was normal -low at 288 mOsm/kg. After administration of a nasal spray of desmopressin, the 24 h urinary volume decreased to 1800 mL. Plasma osmolality increased to 596 mOsm/kg.A diagnosis of anterior and posterior hypopituitarism was therefore proposed. Th e patient was th...

Diabetes Insipidus: Little-Known Facts

“…(2013) также описали ЦНД, представляющий собой раннее проявление острого миелоидного лейкоза [26], W. L. Zheng (2016) -два случая неходжкинской лимфомы с поражением гипофиза [27], а O. Malaise (2012) -НД, развившийся при первичной лимфоме центральной нервной системы (ЦНС) [28].…”